2019-2020 Cohort
IV. Income Documentation:
Are you: a dependent or independent? (24 years of age or other financial aid & federal guidelines)
Number in family:
You must provide current financial documentation or complete a FAFSA® for program requirements.
Date:
Student’s Typed Name
To determine your taxable income, refer to your and/or parents’ 2018
Federal income tax return:
Line 6 on Form 1040 EZ
Line 27 on Form 1040 A
Line 43 on Form 1040
If you are applying to the SSS program as a low income participant, you
will need to submit a verification of income to the SSS office. The term
“low-income” means an individual whose family’s taxable income for
the preceding year did not exceed 150 percent of the poverty level
1
2
3
4
5
6
7
8
$18,735
$25,365
$31,995
$38,625
$45,255
$51,885
$58,515
$65,145
For family units with more than 8 members,
add $6,630
for each additional family
member.
V. Disability Documentation:
Are you a student with a disability? Yes No
Have you registered with the IRSC Student Accessibility Services (SAS)? Yes No
Note: Documentation of your disability is required. Disability documentation for any Indian River State College student is retained in
confidential files in the Student Accessibility Services Office.
VI. Participants Requirements:
a. I give permission for Student Support Services personnel to access my IRSC academic and student financial aid records for the purpose of verifying
my project eligibility and assisting me academically.
b. I agree to actively participate in Student Support Services activities, including: annual orientation, setting long & short-term goals, development
and updates of a personal education plan and Guided Pathway, Achievers Club, individual tutoring, Success Skills workshops, individual counseling,
cultural enrichment and college tours.
c. Submit verification of income documentation.
d. If disabled, documentation of disabled student status from the Student Accessibility Services Office.
The information I have provided is true and correct to the best of my knowledge. I attest that the documents I have presented for verification of eligibility
are genuine and relate to me. I am aware that any false documents in connection with eligibility will be cause for my dismissal from the STUDENT
SUPPORT SERVICES/TRIO PROGRAM. I also authorize Indian River State College or other postsecondary institutions to release official transcripts, test
scores, financial aid award information and other records to the Indian River State College Student Support Services/TRIO Program for educational
planning purposes. I also authorize Indian River State College Student Support Services/TRIO program to release these records to other institutions as
they relate to my educational planning.
Student’s Typed Name Date
By typing my name below indicates that my child is under 18 years of age and that the information given on this application is true and complete to the
best of my knowledge.
Parent’s Typed Name Date
VII. Release & Waiver of Liability:
As a student of Indian River State College, I hereby acknowledge that membership in the Student Support Services program (SSS) will involve participation in
extracurricular and recreational activities, as well as off-campus student trips. Furthermore, as the undersigned, I hereby release and forever discharge the SSS
program, the Board of Trustees and President of Indian River State College, its members individually, its officers, agents and employees, from any and all claims,
demands, rights, and causes of action and all known and unknown, foreseen and unforeseen bodily and personal injuries, damage to property and consequences
thereof, resulting from participation in or in anyway connected with such activities of the Student Support Services program.
I have read the above carefully before typing my name and fully understand its content. Furthermore, I understand that this release and waiver of liability shall
remain in effect for the duration of my membership and participation in the Student Support Services program.
Student’s Typed Name Date
CONFIDENTIALITY OF INFORMATION The personal information that is provided to the Student Support Services/TRIO Program will be protected under the Family
Educational Rights and Privacy Act of 1974. No one will have access to the information unless he or she works with or for the Student Support Services/TRIO
Program or is specifically authorized by the student in question to see the information. The information is necessary to help determine the success of participants
in post-secondary education as authorized by the U.S. Department of Education. (20 United States code 1231a)
